Deficient Fluid Volume

Deficient Fluid Volume: It is defined as decreased intravascular, interstitial, and intracellular fluid.
May be related to

 Osmotic pressure
 Plasma protein loss
 Decreasing plasma colloid
 Allowing fluid shifts out of the vascular compartment
Possibly evidenced by

 Edema formation
 Sudden weight gain
 Decreased urine output
 Hemoconcentration
 Nausea/vomiting
 Epigastric pain
 Headaches
 Visual changes
Desired Outcomes

 Patient engages in therapeutic regimen and monitoring, as indicated.

 Patient verbalizes understanding of need for close monitoring of weight, BP, urineprotein, and
edema.
 Patient is free of signs of generalized edema (i.e., epigastric pain, cerebral symptoms, dyspnea,
nausea/vomiting)
 Patient exhibits Hct WNL and physiological edema with no signs of pitting.
Nursing Interventions Rationale
Abrupt, notable weight gain (e.g., more than 3.3 lb (1.5
Weigh patient regularly. Tell kg)/month in the second trimester or more than 1 lb (0.5
patient to record weight at kg)/wk in the third trimester) reflects fluid retention.
home in between visits. Fluid moves from the vascular to interstitial space,
resulting in edema.
The presence of pitting edema (mild, 1+ to 2+; severe, 3+
Differentiate physiological and to 4+) of face, hands, legs, sacral area, or abdominal wall,
pathological edema of or edema that does not disappear after 12hr of bedrest is
pregnancy. Locate and vital. Note: Significant edema may actually be present in
determine degree of pitting. nonpre-eclamptic patient sand absent in patients with
mild or moderated PIH.
Note signs of progressive or Edema and intravascular fibrin deposition (in HELLP
excessive edema i.e., syndrome) within the encapsulated liver are manifested
epigastric/RUQ pain, cerebral by RUQ pain; dyspnea, indicating pulmonary
symptoms, nausea, vomiting). involvement; cerebral edema, possibly leading to
Assess for possible eclampsia. seizures; and nausea and vomiting, indicating GI edema.
Identifies degree of hemoconcentration caused by fluid
Note alteration in Hct/Hb
shift. If Hct is less than 3 times Hb level,
levels.
hemoconcentration exists.

Check on dietary intake of
proteins and calories. Give
information as needed.
Monitor intake and output.
Note urinecolor, and measure
specific gravity as indicated.
Examine clean, voided urine for
protein each visit, or
daily/hourly as appropriate if
hospitalized. Report readings
of 2+, or greater.
Assess lung sounds and
respiratory rate/effort.
Check BP and pulse.
Respond to questions and
review rationale for avoiding
use of diuretics to treat edema.
Schedule prenatal visit every
1–2 wk if PIH is mild; weekly if
severe.
Review
moderate sodium intake of up
to 6 g/day. Tell patient to read
food labels and avoid foods
high in sodium(e.g., bacon,
luncheon meats, hot dogs,
canned soups, and potato
chips).
Collaborate with dietitian as
indicated.
Place patient on strict regimen
of bedrest; encourage lateral
position.
Educate patient and family
members or significant others
on home monitoring/day-care
program, as appropriate.
Substitute fluids either orally
or parenterally via infusion
pump, as indicated.
Proper nutrition decreases incidence of
prenatal hypovolemia and hypoperfusion; insufficient
protein/calories increases the risk of edema formation
and PIH. Intake of 80–100 g of protein may be required
daily to replace losses.
Urine output is a sensitive indicator of
circulatory blood volume. Oliguria and specific gravity of
1.040 indicate
severe hypovolemia and kidney involvement. Note:
Administration of magnesiumsulfate (MgSO4)may cause
transient increase in output.
Aids in identifying degree of severity/progression of
condition. A 2+ reading implies glomerular edema or
spasm. Proteinuria affects fluid shifts from the vascular
tree. Note: Urine contaminated by vaginal secretions may
test positive for protein, or dilution may result in a false-
negative result. In addition, PIH may be present without
significant proteinuria.
Dyspnea and crackles may mean pulmonary edema,
which needs immediate treatment.
Rise in BP may happen in response to catecholamines,
vasopressin, prostaglandins, and, as recent findings
suggest, decreased levels of prostacyclin.
Diuretics further increase chances of dehydration by
decreasing intravascular volume and placental perfusion,
and they may cause
thrombocytopenia, hyperbilirubinemia, or alteration in
carbohydrate metabolism in fetus/newborn. Note: May
be useful in treating pulmonary edema.
Important to monitor changes more closely for the well-
being of the patient and fetus.
Some sodium intake is necessary because levels below
2–4 g/day result in greater dehydration in some patients.
However, excess sodium may increase edema formation.
Nutritional consult may be beneficial in determining
individual needs/dietary plan.
Lateral recumbent position decreases pressure on
the vena cava, increasing venous return and circulatory
volume. This enhances placental and renal perfusion,
reduces adrenal activity, and may lower BP as well as
account for weight loss through diuresis of up to 4 lb in
24-hr period.
Some mildly hypertensive patients
without proteinuria may be managed on an outpatient
basis if adequate surveillance and support is provided
and the patient/family actively participates in the
treatment regimen.
Fluid replacement treats hypovolemia, yet must be given
cautiously to prevent overload, especially if interstitial
fluid is drawn back into circulation when activity is
reduced. With renal involvement, fluid intake is
restricted; i.e., if output is reduced (less than 700 ml/24
 hr), total fluid intake is restricted to approximate output
plus insensible loss. Use of infusion pump allows more
accurate control delivery of IV fluids.

Situational Low Self-Esteem

Situational Low Self-Esteem: Development of a negative perception of self-worth in response to current

situation.
May be related to

 Perceived failure at a life event

Possibly evidenced by

 Verbalization of negative feelings about the self

(helplessness, uselessness)
 Negative self-appraisal in response to life event in a
person with a previous positive self-evaluation
 Difficulty making decisions
Desired Outcomes

 Patient demonstrates adaptation to death of infant and integration of loss into daily life by
planning for the future.
 Patient identifies strengths and resources available.
 Patient expresses positive self-appraisal.
Nursing Interventions
Identify couple’s self-
perceptions as individuals and
parents. Assess family’s
response to loss, noting blame
placed by family members.
Review with parent(s) what
has happened and discover
how they perceive the death.
Explore destructive behaviors,
differentiating the responses
of others from self-elicited
responses (e.g., expressions of
blame and/or guilt)
Present positive
reinforcement for expressing
needs and identifying
concerns.
Rationale
Giving birth provides opportunities for giving love, being
loved, building self-esteem, feeling proud and
accomplished, establishing a reason for living, and
creating a bridge to the future. Loss of the pregnancy
and newborn is, therefore, frequently associated with
feelings of inadequacy, powerlessness, and inferiority,
directly affecting sense of self and possibly shattering
one’s self-esteem as a parent. Expression of anger or
blame by other family members may further reduce self-
esteem. Note: Sense of loss/failure may be exacerbated in
cases of repeated miscarriages or serial fetal/neonatal
deaths.
Anger among family members may be transferred to
patient/couple, resulting in a distortion of actual events.
Destructive behaviors may be obvious during the phases
of anger, isolation, and depression. Denial may be used as
protection against loss of self-esteem. Guilt may be
verbalized, especially if the loss is related to a genetic
problem, uterine trauma (e.g., car accident or fall), or
teratogens from environmental exposure or drug
ingestion.
Helps in coping with sadness of situation. Aids parents
accept themselves as worthy human beings.
 Continuing to care and to feel needed assists
Consider parenting needs of
in preserving patient’s/couple’s identify as worthwhile
other children, as appropriate.
parent(s).
Sharing of loss provides opportunity for
Provide opportunity for
needed acceptance, helps parents sort through feelings,
verbalization, venting of
and validates parents’ normal feelings of powerlessness
emotions, and crying.
and inadequacy.
Consider referrals for
Patient’s/couple’s ability to coordinate and perform tasks
counseling and assist with
may be compromised. Referrals help provide support and
coordination of appointments
assistance, which can facilitate integration of loss into
(e.g., with social services or
daily life and enhance self-esteem.
support groups)

WHAT HAPPENS TO THE FLUID BALANCE IN SURGERY

Homeostasis defines the tendency of the organism to maintain stability and balance. In this manner, body
fluid balance is controlled by previously described compartment mechanisms. On the other hand, any
physical intervention may cause imbalance of the body fluids. During relatively long lasting major
surgeries, which are performed with general anesthesia, whole intake is controlled by the
anesthesiologist and fluid loss happens in numerous different ways such as bleeding, drainage of ascites,
urination, insensible water loss and “third space losses”. Intraoperative management of acute losses is
not covered in this article. However, long term effects of these intraoperative events, such as possible
over-hydrating by the anesthesiologist, dehydration, and bleeding should be considered in the
postoperative care unit.
The third space is a term for spaces in which body fluids lose their function to affect fluid balance
between intravascular and extravascular compartments. In other words, it can be called as non-
functional extracellular volume. Bowel lumen, peritoneal and pleural cavities are thought to be the major
examples of the third space. Studies that tried to explain the third space loss measured the extracellular
volume (ECV) and functional ECV (fECV). fECV is defined as fluid accumulations within the interstitial
space combined with plasma. Shires showed that, there is up to 28% loss in extracellular volume after
two hours of operative time, during elective surgeries of thirteen adult patients[4]. Subsequent studies in
1960s support this finding and existence of the third space[10-12]. However, numerous trials with
improved methodology proved that fECV levels do not decrease in or after surgery[13-16]. This
correction of data couldn’t be recognized well enough, but still, favored common belief is in the presence
and importance of the third space. Current evidence supports that fECV is not negatively affected by
surgery, however over-hydration with saline and surgical trauma cause endothelial dysfunction and
interstitial edema due to fluid shift to ECV[13]. In conclusion, “the third space” term should only refer to
anatomical cavities like bowel lumen, peritoneum and pleura, and should only be considered in certain
cases. Moreover, possible endothelial glycocalyx dysfunction and fluid shift to ECV should be our guiding
facts for determining the right strategy in postoperative fluid management.
Changes in the water and electrolyte content of the body tissues after surgical operations occur as the
result of two factors. On the one hand, there are the various changes consequent upon altered intake and
excessive loss of these materials, as, for example, in disorders affecting the gastrointestinal tract and with
haemorrhage, and on the other hand, there are several less specific but equally important changes which
occur as the physiological response to trauma. The latter, which were first observed in detail by
Cuthbertson (1930) and have been studied minutely in recent years (Moore and Ball, 1952; Wilkinson et
al., I950, and others), are reviewed elsewhere in this issue and will only be mentioned here in relation to
the genesis and treatment of individual fluid and electrolyte disturbances. It is often argued that patients
survived major surgical operations and illnesses long before these newer ideas were conceived, but, of
course, the same is true for antibiotics and modern anaesthesia, the value of which no one would deny,
and prevention of a complication still remai'ns better than its cure.
Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
May be related to

 lack of knowledge regarding symptoms, progression of condition, and treatment regimen.

 actual or perceived threat to biologic integrity.
 unconscious conflict about essential values and goals of life.
  Situational and maturational crises.
Possibly evidenced by
 Decreased attention span
 Restlessness
 Poor impulse control
 Hyperactivity, pacing
 Feelings of discomfort, apprehension or helplessness
 Delusions
 Disorganized thought process
 Inability to discriminate harmful stimuli or situations
Desired Outcomes
 Be free from injury
 Discuss feelings of dread, anxiety, and so forth
 Respond to relaxation techniques with a decreased anxiety level.
 Reduce own anxiety level.
 Be free from anxiety attacks.
Nursing Interventions
Maintain a calm, non threatening manner while
working with the client.
Establish and maintain a trusting relationship
by listening to the client; displaying warmth,
answering questions directly, offering
unconditional acceptance; being available and
respecting the client’s use of personal space.
Remain with the client at all times when levels
of anxiety are high (severe or panic); reassure
client of his or her safety and security.
Move the client to a quiet area with minimal
stimuli such as a small room or seclusion area
(dim lighting, few people, and so on.)
Maintain calmness in your approach to the
client.
Provide reassurance and comfort measures.
Educate the patient and/or SO that anxiety
disorders are treatable.
Support the client’s defenses initially.
Maintain awareness of your own feelings and
level of discomfort.
Rationale
Anxiety is contagious and may be
transferred from health care provider to
client or vice versa. Client develops
feeling of security in presence of calm
staff person.
Therapeutic skills need to be directed
toward putting the client at ease,
because the nurse who is a stranger may
pose a threat to the highly anxious
client.
The client’s safety is utmost priority. A
highly anxious client should not be left
alone as his anxiety will escalate.
Anxious behavior escalates by external
stimuli. A smaller or secluded area
enhances a sense of security as
compared to a large area which can
make the client feel lost and panicked.
The client will feel more secure if you
are calm and inf the client feels you are
in control of the situation.
Helps relieve anxiety.
Pharmacological therapy is an effective
treatment for anxiety disorders;
treatment regimen may
include antidepressants and anxiolytics.
The client uses defenses in an attempt to
deal with an unconscious conflict, and
giving up these defenses prematurely
may cause increased anxiety.
Anxiety is communicated
interpersonally. Being with an anxious

Stay with the patient during panic attacks. Use
short, simple directions.
Avoid asking or forcing the client to make
choices.
Observe for increasing anxiety. Assume a calm
manner, decrease environmental stimulation,
and provide temporary isolation as indicated.
PRN medications may be indicated for high
levels of anxiety. Watch out for adverse side
effects.
Encourage the client’s participation in
relaxation exercises such as deep breathing,
progressive musclerelaxation, guided imagery,
meditation and so forth.
Teach signs and symptoms of escalating anxiety,
and ways to interrupt its progression (e.g.,
relaxation techniques, deep- breathing
exercises, physical exercises, brisk walks,
jogging, meditation).
Administer SSRIs as ordered.
Help the client see that mild anxiety can be a
positive catalyst for change and does not need
to be avoided.
Cognitive-behavioral therapy (further discussed here)
Positive reframing
Decatastrophizing
Assertiveness training
When level of anxiety has been reduced, explore Recognition of precipitating factors is
with the client the possible reasons for
occurrence.
Encourage client to talk about traumatic
experience under nonthreatening conditions.
Help client work through feelings of guilt
related to the traumatic event. Help client
client can raise your own anxiety
level. Discussion of these feelings can
provide a role model for the client and
show a different way of dealing with
them.
During a panic attack, the patient needs
reassurance that he is not dying and the
symptoms will resolve spontaneously.
In anxiety, the client’s ability to deal
with abstractions or complexity is
impaired.
The client may not make sound and
appropriate decisions or may unable to
make decisions at all.
Early detection and intervention
facilitate modifying client’s behavior by
changing the environment and the
client’s interaction with it, to minimize
the spread of anxiety.
Medication may be necessary to
decrease anxiety to a level at which the
client can feel safe.
Relaxation exercises are effective
nonchemical ways to reduce anxiety.
So the client can start using relaxation
techniques; gives the client confidence
in having control over his anxiety.
Panic attacks are caused by
neuropsychiatric disorder that responds
to SSRI antidepressants.
The client may feel that all anxiety is bad
and not useful.
Turning negative messages into positive
ones.
It involves the therapist’s use of
questions to more realistically appraise
the situation. It is also called the “what
if” technique because the worst case
scenario is confronted by asking a “what
if” question.
Helps the person take more control over
life situations. These techniques help the
person negotiate interpersonal
situations and foster self-assurance.
the first step in teaching client to
interrupt escalation of anxiety.
Verbalization of feelings in a
nonthreatening environment may help
client come to terms with unresolved
issues.
understand that this was an event to which
most people would have responded in like
manner. Support client during flashbacks of the
experience.